Whelby Dental

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We found this practice was not providing well-led care in accordance with the relevant regulations. We will be following up on our concerns to ensure the provider had made the required improvements.

During our inspection of this key question, we found a lack of systems or processes that enabled the registered person to assess, monitor and improve the quality and safety of the services being provided.

The registered person had systems or processes in place that operated ineffectively in that they failed to enable the registered person to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk.

This resulted in a breach of Regulation 17, Good governance.

You can find more details of our concerns in the detailed findings below.

Find out what we look at when we assess this area in our information about our new Single assessment framework.

The judgement for Shared direction and culture is based on the latest evidence we assessed for the Well-led key question.

The judgement for Capable, compassionate and inclusive leaders is based on the latest evidence we assessed for the Well-led key question.

The judgement for Freedom to speak up is based on the latest evidence we assessed for the Well-led key question.

The judgement for Workforce equality, diversity and inclusion is based on the latest evidence we assessed for the Well-led key question.

The practice had a governance system that included policies and procedures, which were accessible to staff and were reviewed on a regular basis.

There was a lack of sufficient governance and oversight to identify and manage various risks, including risks associated with dental radiography, medical emergencies, Legionella and fire risk management. Areas requiring improvement were acted on immediately demonstrating the practices commitment to making improvements for both staff and patients. However, there was scope to ensure these systems were embedded within the practice and staff.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records, and paper records were stored securely and complied with General Data Protection Regulations. However, there was scope to ensure patients reference numbers were used during external communications.

Processes for investigating incidents and accidents were effective. There was scope to ensure the processes for receiving and acting on safety alerts were documented and available for all staff

The practice had some systems and processes for learning, quality assurance and continuous improvement. This included undertaking audits which was not always in line with recognised guidance as infection control and radiation audits needed to be carried out every 6 months rather than annually.

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement. However, these were not always logged. We discussed this with the practice leader who confirmed these would be documented in future.

There was a lack of staff responsibilities, and systems of accountability to support good governance.

Staff feedback was obtained through meetings, appraisals and informal discussions. They were encouraged to offer suggestions for improvements to the service, and they said these were listened to and acted upon, where appropriate.

The practice gathered feedback from patients, the public and external partners, and responded accordingly.

The judgement for Partnerships and communities is based on the latest evidence we assessed for the Well-led key question.

The judgement for Learning, improvement and innovation is based on the latest evidence we assessed for the Well-led key question.